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oF PRIp� CITY OF PRIOR LAKE BUILDING PERMIT, Date Rec'd
,� � TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
.``. x AND UTILITY CONNECTION PERMIT
� �
'1�j I. White File pERMIT NO.
2. Pink Ciry /� � ��J
3 Yellow Applicant /
i
Please or rint and si at bottom
ADDRESS , ZOIVING (ot�ice use)
�� l , � �� �°! /lD�l �rQi i ( � �
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�WNER `� / � S /' / �CiLL�-- (Phone) ��a `�� �o? � S
/�
�
(Address) ,�7 9 �7 S ,�� � , � -S �
BUII..DER
(Company Name) (Phone)
(Contact Name) (Phone)
(Address)
TYPE OF WORK ❑ New Construction ❑Deck ❑Porch ❑Re-Roofing �ke-Siding ❑Lower Level Finish ❑ Fireplace
❑Addition ❑Alteration ❑Urility Connection
CODE: ❑I.R.C. ❑I.B.C. ❑ Misc.
Type of Construction: I II III N V A B pROJECT COST/VALiTE $ �. A[s �
Occupancy Group: A B E F H I M R S U (excluding land)
Division: 1 2 3 4 5
1 hereby certify that l have fiimished information on this application which is to the best of my knowledge true and corcect. 1 also certify that I am the owner ur author�zed agent for thc
above-menuoned property and that all cunstruction wiU conform ro all existing stare and local laws and will proceed in accordance with submitted plans. I am aware that the buildmg
official can r ke s permit for just cause. Furtherm e, I hereby agree that the city official or a designee may enrer upon the property to perform necded mspections.
X G�:�%�— �
Signature Contractor's License No. Date
Permit Valuation Park Support Fee # $
Permit Fee $ SAC # $
Plan Check Fee $ Water Meter Size 5/8"; 1"; $
State Surcharge $ Pressure Reducer $
Penalty $ Sewer/Water Connection Fee # $
Plumbing Permit Fee $ Water Tower Fee # $
Mechanical Permit Fee $ Builder's Deposit $
Sewer & Water Permit Fee $ Other $
Gas Fireplace Permit Fee $ TOTAL DLTE $ . 7�
This Apptication Becomes Your Building Permit When Approved Paid ' ReCei t N.
Date / t B
Buildine Utticial Date
This �s to certify that the requcst in the abuve applicauon and accompanying documents is in accordance with the Ciry Zoning Ordinantt and may proceed as rcqucsted. Th1s ducument
when signed by the Ciry Planner cunsututes a tempurary Certificate of Zoning compliance and allows construction to commence. Befure uccupancy, a Certrficate uf Occupancy must be
issucd.
Planning Direcror Date Special Conditions, if any
24 hour noticc for all inspections (9S2) 447-9850, fax (952) 447-4245
4646 Dakota Street Prior Lake, MN 55372